Runner’s knee — or patellofemoral pain (PFP) — is one of the most common injuries I see in clinic, and one of the most frequently mismanaged. Research published in the British Journal of Sports Medicine found that more than 50% of people with this condition still have symptoms five years after diagnosis, despite receiving treatment (Neal et al., 2024). That reflects not how difficult PFP is to treat, but how often it is treated incorrectly.
This blog covers what patellofemoral pain is, what causes it, how to recognise it, how it should be assessed, and what the evidence says works.
For details of how we can work with you, visit our Physiotherapy main page https://www.evolverehabtherapy.co.uk/physiotherapy-and-sports-therapy-2/
1. What Is Patellofemoral Pain?
Pain Behind and Around the Kneecap
Patellofemoral pain is defined as pain around or behind the kneecap, aggravated by activities that load the patellofemoral joint during weight-bearing on a bent knee — running, descending stairs, squatting, and prolonged sitting (Neal et al., 2024). It develops gradually, often on one or both knees, with no single moment of injury and no associated structural damage.
It is a clinical diagnosis based on symptoms and how they behave. Imaging findings do not reliably match symptoms, and a scan in isolation is not a diagnosis.
2. Causes and Risk Factors
Patellofemoral pain is multifactorial. The evidence on its causes is more contested than most patient-facing content suggests. Training load is the most consistently implicated modifiable factor — too much, too soon, without adequate adaptation time. High peak hip adduction during running carries prospective evidence as a risk factor in female runners, and quadriceps weakness shows moderate prospective evidence in military populations (Neal et al., 2019).
| What is confirmed: training load spikes, high peak hip adduction during running, quadriceps weakness in active populations. |
| What is not confirmed as a cause: hip weakness (likely a consequence of reduced activity rather than a cause), Q-angle, BMI, and overpronation are widely cited but not supported by prospective evidence (Neal et al., 2019). |
This matters because it shapes what a proper assessment and management should look for, and why a generic programme is rarely enough.
3. Symptoms: Recognising the Pattern
The hallmark is a diffuse ache or sharp pain around or behind the kneecap – often difficult to pinpoint to a single spot.
It gets worse with:
- Descending stairs and downhill running
- Squatting, lunging, and deep knee bend positions
- Prolonged sitting — the ‘theatre sign’: knee aches during extended sitting, eases when you stand and move
The typical pattern:
- Fine for the first few kilometres, then builds through the run
- Often eases during warm-up, then returns afterwards
- Settles with rest, returns as soon as load does
Pain that is constant at rest, wakes you from sleep, or is sharply localised to one specific point warrants careful assessment to rule out other diagnoses.
4. Assessment
A thorough assessment identifies what is actually driving the problem, not just where it hurts. At Evolve, this covers:
- Load history – what changed recently in your training?
- Objective strength testing using a hand-held dynamometer (HHD) – numbers, not guesswork
- Functional testing – single-leg squats, step-downs, hop tests
- Movement quality under load – knee valgus, hip drop, trunk position
- Running mechanics where symptoms are linked to how you move
- Ruling out other diagnoses – tendinopathy, hip pathology, meniscal issues
| 👉 Want a proper assessment of your runner’s knee? We use HHD strength testing and functional assessment at Evolve. Book in with us. Appointment booking and email contact |
5. How to Manage Patellofemoral Pain
Addressing patellofemoral pain requires the right combination of exercise, load management, and education. A systematic review of 65 high-quality trials confirmed six interventions with positive effects (Neal et al., JOSPT 2022; Neal et al., BJSM 2024).
Early-stage management – controlling pain
In the early stages, the priority is reducing the load provoking symptoms without stopping activity entirely. These measures do not fix the problem – but they help manage pain while rehabilitation gets underway.
- Reduce running load temporarily: cut back on volume and intensity, or switch to lower-impact alternatives such as cycling or swimming to maintain fitness without aggravating the knee.
- Avoid the activities that most provoke symptoms: descending stairs, downhill running, and deep squatting are common aggravators. Reducing these in the short term allows irritation to settle.
- Ice after activity: can be used as a short-term comfort measure to help manage pain. The evidence for its therapeutic effect in chronic overuse conditions is limited, but many people find it helpful.
- Over-the-counter pain relief: may help manage symptoms in the short term. Speak to your GP or pharmacist about what is appropriate for you.
- Patellar taping: a well-evidenced short-term pain management tool that can allow you to stay active while rehabilitation begins.
Exercise therapy – the foundation
Knee-targeted exercise therapy produces the largest effect size of any intervention tested. Adding hip work on top of knee-targeted exercise improves outcomes further – a meta-analysis of 14 trials confirmed combined hip and knee strengthening is superior to knee work alone (Nascimento et al., 2018). When isolated hip and knee strengthening are compared head-to-head, they produce equivalent outcomes — meaning combining both is the most effective single approach (Na et al., 2021). Education alongside exercise is not optional and understanding your condition changes outcomes.
- Knee exercises: wall squats, step-downs, leg press, terminal knee extensions
- Hip exercises: side-lying hip abduction, clamshells, hip external rotation, bridges
- Single-leg progressions: single-leg squat, step-up, single-leg Romanian deadlift
Aim for 2–4 sessions per week. Intensity matters – exercises must be challenging, working to near-muscular fatigue. Submaximal, easy loading does not drive adaptation (Llanos-Lagos et al., 2024). Expect 8–12 weeks of consistent work before drawing conclusions.
Additional interventions
- Foot orthoses — evidence for short-term benefit in appropriate cases
- Manual therapy — evidence for improved function
- Patellar taping — useful short-term pain management tool
- Running retraining — adjusting cadence and step width where mechanics are a factor
| What the evidence does not support Dry needling has no effect on pain or function in meta-analysis (Neal et al., 2024). Rest alone does not resolve PFP — symptoms return as soon as load does. Light, easy exercise at the wrong intensity will not drive the tissue adaptation needed. |
| 👉 Ready to start the right treatment? We build properly dosed, progressed programmes at Evolve. Book in with us. Appointment booking and email contact |
Returning to running
Complete rest is rarely the answer. Modify the load — do not eliminate it. Reduce volume and intensity while maintaining frequency where possible. Avoid downhill running and speed work initially. A 5–10% increase in running cadence can reduce load at the patellofemoral joint and is worth trialling. Strength work runs alongside your running throughout — not instead of it.
- Start with shorter, easier runs on flat surfaces
- Avoid hills and speed work until symptoms are well controlled
- Increase load gradually, guided by your 24–48 hour symptom response
- Continue strength work throughout your return to full training
| 👉 Not sure whether to keep running or how to modify training? We can help you make that decision with confidence. Book in with us at Evolve. Appointment booking and email contact |
6. Prevention
The same principles that drive good rehabilitation reduce the risk of PFP developing in the first place.
- Manage training load carefully — avoid sudden spikes in volume or intensity, particularly when adding speed work, hills, or back-to-back sessions
- Strength train consistently — 2–4 sessions per week, progressed to near-fatigue (Leppänen et al., 2024)
- Do not ignore early symptoms — addressing load and beginning rehabilitation early produces far better outcomes than waiting
- Previous injury is the strongest risk factor for future injury (Fokkema et al., 2023) — a structured return to running after any injury significantly reduces recurrence risk
Summary
Patellofemoral pain responds well to the right treatment — exercise therapy, education, appropriate loading, and a programme that is progressed correctly. What it does not respond to is rest alone, passive treatment, or easy exercise at the wrong intensity.
If your runner’s knee has been bothering you, get a proper assessment — not just to find where it hurts, but to understand what is driving it and build a plan that addresses the cause.
| Book in with us at Evolve — we will assess your load, strength, and movement, and build a programme that gets you back running properly. Appointment booking and email contact |
References
Fokkema, T., Varkevisser, N., de Vos, R-J., Bierma-Zeinstra, S.M.A., & van Middelkoop, M. (2023). Factors associated with running-related injuries in recreational runners with a history of running injuries. Clinical Journal of Sport Medicine, 33(1), 61–66.
Leppänen, M., et al. (2024). Hip and core exercise programme prevents running-related overuse injuries in adult novice recreational runners: a three-arm randomised controlled trial (Run RCT). British Journal of Sports Medicine, 58(13), 722–732.
Llanos-Lagos, C., Ramirez-Campillo, R., Moran, J., & Sáez de Villarreal, E. (2024). Effect of strength training programmes in middle- and long-distance runners’ economy at different running speeds: a systematic review with meta-analysis. Sports Medicine, 54(4), 895–932.
Na, Y., Han, C., Shi, Y., Zhu, Y., Ren, Y., & Liu, W. (2021). Is isolated hip strengthening or traditional knee-based strengthening more effective in patients with patellofemoral pain syndrome? A systematic review with meta-analysis. Orthopaedic Journal of Sports Medicine, 9(7), 23259671211017503.
Nascimento, L.R., Teixeira-Salmela, L.F., Souza, R.B., & Resende, R.A. (2018). Hip and knee strengthening is more effective than knee strengthening alone for reducing pain and improving activity in individuals with patellofemoral pain: a systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 48(1), 19–31.
Neal, B.S., Bartholomew, C., Barton, C.J., Morrissey, D., & Lack, S.D. (2022). Six treatments have positive effects at 3 months for people with patellofemoral pain: a systematic review with meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 52(11), 750–768.
Neal, B.S., Lack, S.D., Lankhorst, N.E., Raye, A., Morrissey, D., & van Middelkoop, M. (2019). Risk factors for patellofemoral pain: a systematic review and meta-analysis. British Journal of Sports Medicine, 53(5), 270–281.
Neal, B.S., Lack, S.D., Bartholomew, C., & Morrissey, D. (2024). Best practice guide for patellofemoral pain based on synthesis of a systematic review, the patient voice and expert clinical reasoning. British Journal of Sports Medicine, 58(24), 1486.
van der Worp, M.P., ten Haaf, D.S.M., van Cingel, R., de Wijer, A., Nijhuis-van der Sanden, M.W.G., & Staal, J.B. (2015). Injuries in runners: a systematic review on risk factors and sex differences. PLoS ONE, 10(2), e0114937.
